La Consolacion University Philippines

College of Medicine
Internal Medicine Preceptorial

Medical History

Date: October 13, 2022

Time: 10:00 AM

General Data:
This is a case of Z.D., a 62-year-old married woman, Filipino, a Roman
Catholic, currently residing in Dakila, Malolos, Bulacan, sought consult and was admitted
at Bulacan Medical Center for the 1st time on October 8, 2022.

Informant: Patient and daughter

Reliability: 75%

Chief Complaint: Generalized weakness

History of Present Illness:

1 month prior to admission, the patient experienced generalized weakness with no
other associated symptoms such as fever, chills, nausea, vomiting, headache, difficulty
of breathing nor chest pain. The patient also claimed that the said symptom was observed
abruptly with no triggering factors. There was no medication, laboratory work-ups nor
other medical intervention was done. However, the patient claimed that she went to seek
help to an albularyo but did not discuss further as to why she visited, what happened
during and after her visit. The manner of time and the frequency of the said symptom was
not asked.

During the interim, there were no improvement noted with the patient and still the
same symptom was present.

3 weeks prior to admission, the weakness progressed more and this time the
patient claimed that it was felt every day during morning until the afternoon. There was
still no medication, consultation, laboratory work-ups nor medical intervention
accomplished. The patient also claimed that there were still no other accompanied
symptoms.

During the interim, the patient still presented the same severity of her weakness.

1 week prior to admission, the patient complained the same generalized weakness
however, it was now associated with other symptoms such as headache, loss of appetite
due to depleted sense of taste and a remarkable weight loss. The patient stated that she
took Flexidol as a self-medication, with an unrecalled dosage and was taken as needed
for pain to which it afforded relief.

3 days prior to admission, the same symptoms of weakness were still noted and
was now accompanied with constipation. There was no medication, consultation,
laboratory work-ups nor medical intervention accomplished,

2 days prior to admission, the patient still had a noticeable loss in her appetite with
progressive weakness which prompted consultation to a clinic. The CBG was taken with
a result of 500mg/dL to which she was diagnosed to have Diabetes Type 2. The patient
was prescribed with Gliclazide 60 mg BID for elevated blood sugar, Clarion
(clarithromycin), and Neuromax of an unknown dosage and frequency taken. However,
these medications were not taken by the patient due to her relatives’ decision to stop
giving it since the patient was not taking any meal. The patient also had leg tremors which
manifested with elevated blood sugar.

1 day prior to admission, the patient felt nausea but there was no associated
vomiting. There were no given medication or other interventions to the said symptom.

Few hours prior to admission the weakness progressed which worsened the
patient’s overall disposition which prompted them to consult and was subsequently
admitted.

Past Medical History:

1. Childhood Illnesses
Unrecalled date: Chicken pox
2. Adult Illnesses
- No noted history
3. Past Hospital Admission
- No noted history
4. Psychiatric History
- No noted history
5. Surgical
- No noted history
6. Immunizations
Childhood immunizations
Unrecalled date: Complete vaccinations
Adult Immunization: No Noted History
7. Screening
- No screenings noted

Family History: To be asked: If no history of hypertension, diabetes, or cancer

Maternal:
Mother: Deceased at 80 years old due to old age
Grandmother: Deceased at 110 years old due to old age
Grandfather: Died at unrecalled age due to unknown disease

Paternal:
Father: Deceased at 80 years old due to unknown disease involving the gastrointestinal
Grandmother: Deceased at 100 years old due to old age
Grandfather: Died at 100 years old due to unknown disease
Uncle and Aunts: Died at unrecalled age due to unknown disease

Personal and Social History:

Patient is a Grade 5 completer from Samar. She was not able to work and stayed
at home as a housewife since she had a total of 9 children. She currently resides in a
bungalow type of house Their family consists of 3 members with her husband and 1 of
their children staying with them. Their house is situated near plant field. They use water
from the well situated at the mountain for cooking and for drinking usage. Their electricity
supply was from Norsamelco. Their waste management is usually burning their garbage
at their backyard. They do not observe waste segregation.
 The patient is an alcohol drinker that drinks occasionally. The patient smokes 10
sticks / half pack a day for 33 years = 16.5 pack/year smoking history. The patient claimed
that she stopped smoking for more than 2 years. She also stated that she never used
prohibited drugs.

The patient’s usual diet is more on vegetables and fruits fresh from their farm. The
patient stated that she also eats chicken and pork meat. Her caffeine intake was usually
in the morning and in the afternoon. She does not take any vitamins.

In her everyday life, he usually wakes up at 3-4am in the morning and usually loves
going to the farm, cutting the grass, planting and watering the areas covered with plants.
At night, she usually sleeps at 8-9pm.

Obstetric-Gynecologic History

The patient’s menarche is at 16 years-old. The patient stated that she has a
monthly regular menstruation with a duration of 3 days. During the menstruation, the
patient claimed that she uses clothed napkins however, the amount of used pads for 24
hours were not recalled. The patient also claimed that she does not experience any
dysmenorrhea during her menstruation.

LMP: Unrecalled
PMP: Unrecalled

The patient was unable to recall her menopausal age.

OB Score:
Gravidity/Parity: G10P9 (T9 P0 A1 L9)
G1: 1977 – Male, normal delivery, at home with midwife, full term, no complications
G2: 1980 – Female, normal delivery at home with midwife, full term, no complications
G3: 1983 – Female, normal delivery at home with midwife, full term, no complications
G4: 1985 – Female, normal delivery, at home with midwife, full term, no complications
G5: 1987 – Female, normal delivery at home with midwife, full term, no complications
G6: 1991 – Male, normal delivery at home with midwife, full term, no complications
G7: Unrecalled year – Abortus, not asked if d/c was done
G8: 1997 – Male, normal delivery at home with midwife, full term, no complications
G9: 2000 – Female, normal delivery at home with midwife, full term, no complications,
deceased at 13 years old due to unknown disease.
G10: 2002 – Male, normal delivery at home with midwife, full term, no complications

There were no Gynecologic History of diseases, infections, vaccinations and screening.

Sexual History
The patient’s coitarche was when she was at 15 years-old. Her last intimate
physical contact was with her husband. She was faithful to her husband from the first time
they have met until now and has no other sexual partners. The patient stated that they
never used contraceptives before such as condoms and pills. There was no history of
dyspareunia or any difficulties during sexual contact. There was no noted history and
medications for STD and HIV.
Review of Systems: (change font color to red if present if your patient)
General:
□ Weight loss ( %) □ Fatigue □ Fever
□ Weight gain ( %) □ Weakness □ Chills
□ Trouble sleeping

Skin:
□ Rashes □ Lumps □ Itching
□ Dryness □ Color changes □ Moles
□ Hair and nail changes □ Scar

Head:
□ Headache □ Head injury □ Dizziness
□ Light headedness

Eyes:
□ Vision □ Glasses or contact lenses □ Pain
□ Redness □ Blurred or double vision □ Flashing lights
□ Specks □ Glaucoma □ Cataracts
□ Last eye exam □ Excessive tearing □ Discharge (watery)

Ears:
□ Decrease hearing □ Ringing in ears (Tinnitus) □ Vertigo
□ Use of hearing aids □ Earaches □ Discharge

Nose and Sinuses:

□ Nasal Stuffiness □ Discharge □ Itching
□ Hay fever □ Nosebleeds □ Sinus pain
□ Frequent colds

Throat (Mouth and Pharynx):

□ Dental caries □ Gums □ Bleeding gums
□ Dentures □ Sore tongue □ Dry mouth
□ Sore throat □ Hoarseness □ Oral Thrush
□ Non-healing sores □ Last dental exam □ Change in taste

Neck:
□ Lumps □ Swollen glands □ Pain
□ Goiter □ Stiffness of the neck

Breasts:
□ Lumps □ Pain or Discomfort □ Nipple discharge
□ Breast-feeding □ Self-examination practices

Respiratory:
□ Cough (dry or wet, productive) □ Sputum (color and amount)
□ Coughing up blood (hemoptysis) □ Shortness of breath (dyspnea)
□ Wheezing □ Pain with deep breath (Pleuritic pain)
□ Last Chest X-ray

Cardiovascular:
□ Chest pain or discomfort/Tightness □ High blood pressure
□ Palpitations □ Shortness of breath with activity
□ Need to use pillows at night to ease breathing (Orthopnea
□ Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal
Dyspnea)
□ Swelling in the hands, ankles or feet (Edema)
□ Results of past Electrocardiogram (ECG) or other cardiovascular tests.
Gastrointestinal:
□ Swallowing difficulties □ Heartburn □ Change in appetite.
□ Nausea □ Rectal bleeding □ Change in bowel habits
□ Stools color and size □ Pain with defecation □ Constipation
□ Diarrhea □ Abdominal Pain □ Food intolerance
□ Hemorrhoids □ Excessive belching or passing of gas
□ Yellow eyes or skin (Jaundice) □ Liver or gallbladder problems

Urinary:
□ Frequency of urination □ Urgency □ Polyuria (> 10 times a day)
□ Nocturia □ Incontinence □ Flank pain
□ Blood in urine (hematuria) □ Reduced caliber or force of the urinary stream
□ Hesitancy □ Burning or pain during urination
□ Dribbling

Genital: Male
□ Pain with sex □ Hernias □ Penile discharge
□ Sores □ Masses or pain □ Erectile dysfunction
□ STD’s □ Testicular pain □ scrotal pain or swelling

Genital: Female
□ Pain with sex □ Vaginal dryness □ Hot flashes
□ Vaginal discharge □ Itching or rash □ STD’s

Peripheral Vascular:
□ Leg cramps □ Intermittent leg pain with exertion (Claudication)
□ Varicose veins □ Swelling in calves, legs or feet
□ Swelling with redness or tenderness
□ Color change in fingertips or toes during cold weather

Musculoskeletal:
□ Muscle or joint pain □ Stiffness □ Back pain
□ Redness of joint □ Swelling of joints □ Trauma
□ Limitation of motion or activity

Neurologic:
□ Dizziness □ Vertigo □ Seizure
□ Changes in mood, attention , or speech □ Weakness
□ Changes in orientation, memory, insight or judgment □ Headache
□ Numbness □ Fainting □ Tremors
□ Weakness □ Paralysis
□ Tingling/Prickly sensation on both hands and thighs

Hematologic:
□ Ease of bruising □ Ease of bleeding □ Anemia
□ Past transfusions □ Transfusion reactions

Endocrine:
□ Head or cold intolerance □ Excessive Thirst (Polydipsia)
□ Excessive Sweating □ Frequent urination (polyuria)
□ Change in appetite (polyphagia)

Psychiatric:
□ Nervousness □ Depression □ Memory loss
□ Tension □ Suicidal ideations □ Mood
□ Past counseling, psychotherapy or psychiatric admissions
 Physical Examination:
GENERAL SURVEY
Patient is lethargic, coherent, not in respiratory distress, in right lateral decubitus position
and is seen with a catheter attached.
VITAL SIGNS
Blood pressure:120/80mmHg Heart Rate:81rpm Respiratory Rate:20cpm
Temperature:36.9ºC O2 Saturation: 96% Height: - Weight: 5’3” BMI: -

SKIN
Skin is pallor, dry, warm to touch, with edema, no jaundice, macular and papular lesions
in the anterior and posterior torso

HEAD AND NECK

Normocephalic, no deformities, or masses. Hair is generally normal in texture. No scalp
tenderness. Facial features are symmetrical. Skull and face are symmetrical. No cervical
lymphadenopathy noted. With rashes and with papular and macular lesion in the axillary
area, neck and (L) submandibular area observed

EYES
Anicteric sclerae, with periorbital edema, pale palpebral conjunctiva. No redness, no lens
opacity, (-) Red-Orange Reflex on left eye, (+) ROR on the right eye

EARS
Normoset external ear. No skin tags and deformities. No discharge and lesions noted.
Cone of light is present on both ears.

NOSE
Nose is symmetrical, no lesions, masses, deformities. No discharge. No alar flaring.
Nasal septum midline. Normal sinuses.

MOUTH AND PHARYNX

Pale lips and oral mucosa, palates are intact, tongue is symmetrical, uvula is at midline
and not inflamed. The oropharynx is pink with no tonsillar erythema or exudate. There
was no evidence of abnormal masses or leukoplakia. No bleeding. No oral lesions. No
cleft lip or cleft palate.

CHEST AND LUNGS

Symmetric Chest expansion. (+) erythematous rashes (vesicular and macular-like
lesions) on the anterior and posterior chest. No Retraction. No abnormality on the thoracic
wall. No palpable masses or tenderness on the anterior and posterior chest. Equal
Fremitus. (+) crackles on left lower lobe upon auscultation on the anterior and posterior
chest.

CARDIOVASCULAR
Adynamic precordium, PMI 5th left ICS midclavicular line, no lifts, no thrills, no heaves,
S1 heard best at apex, S2 heard best at base, normal rate, regular rhythm, no murmurs

ABDOMEN
Abdomen is symmetrical, flat, skin color is normal, with (+) erythematous rashes (macular
and vesicular lesions) in all 4 quadrants. On auscultation, bowel sounds are normoactive,
no noted bruit over epigastrium and periumbilical areas. No noted splenomegaly and
hepatomegaly, normal liver size. No ascites noted, (-) fluid wave test and (-) shifting
dullness, no noted tenderness, no bulging and no mass.
 RECTAL EXAMINATION
- NOT ASSESSED

GENITALS
- NOT ASSESSED

EXTREMITIES
Symmetrical upper extremities, (+) swelling on both left and right hands, no visible dilated
veins, no pallor or cyanosis, (+) erythematous rashes on both arms. Radial pulse regular,
normal to strong, brachial pulse not assessed, patient refused due to pain from blood
extraction and injection. Capillary refill time is normal, less than 2 seconds. +2 bipedal
edema, weak pulses on both popliteal and dorsalis pedis.

NEUROLOGICAL EXAMINATION (NOT COMPLETELY DONE, ONLY FEW PARTS)

Cerebrum: Conscious, coherent, oriented to time, place and person; and able to follow
simple commands

Cerebellum: Patient able to do:

1. Finger to Nose test- the patient was able to do but in a slower phase
2. Heel to Shin test- the patient was unable to perform
3. Rapid alternating movements of arms- the patient was able to do but in a slower phase
4. Walk across the room or down the hill- the patient was unable to perform

CN I: able to identify odor of different substances e.g., coffee

CN II: 2-3mm, equally reactive to light and accommodation
CN III, IV, VI: intact EOMs, (-) nystagmus
CN V: (+) corneal reflex
CN VII: no facial asymmetry
CN VIII: intact gross hearing
CN IX, X: (+) Gag reflex – not able to perform since the preceptor did not allow
CN XI: can shrug and elevate shoulders
CN XII: tongue in midline

3/5 3/5

2/5 2/5

(-) Babinski
(-) Nuchal rigidity
(-) Kernig’s, (-) Brudzinski

Fundoscopy: (+) Red-Orange Reflex on R eye (-) ROR on L eye, (-) Papilledema
Pertinent positives:
• 62-year-old woman
• Generalized weakness
• Headache
• Loss of appetite
• Weight loss
• Nausea
• Lethargic
• Diagnosed with Diabetes Type 2
• CBG upon admission: 468 mg/dl
• Sedentary lifestyle
• Smoker and Alcoholic beverage drinker
• Pallor
• Rashes with macular and popular lesions
• Blurring of vision
• Polyuria
• Polydipsia
• Numbness, tingling and prickly sensation on both hands
• (-) ROR on left eye
• (+) dental caries
• +2 bipedal edema

Primary Impression and basis: Hyperglycemic Hyperosmolar state secondary to

Uncontrolled diabetes mellitus type 2, CVA, Anemia of chronic disease, t/c
chronic kidney disease.

Based on the history, Patient Z.D., experienced generalized weakness for a month
accompanied with weight loss, loss of appetite and nausea. She also become lethargic
due to the continued symptoms. As she is diagnosed with diabetes mellitus type 2
upon admission, we can’t be sure when it really started considering she is experiencing
uncontrolled diabetes mellitus symptoms. This can progress to hyperglycemic
hyperosmolar state which show the polyuria, blurred vision and weight loss, this
culminates to the lethargy of the patient. This is because of the marked hyperglycemia,
and associated with the possible CVA incidence of the patient leading to HHS. It is also
considered that she has risk factors such as her old age, sedentary lifestyle, smoker,
and alcoholic beverage drinker.

Based on some study, there are possible mechanisms where in Diabetes leads to stroke.
These include vascular endothelial dysfunction, increased early-age arterial stiffness,
systemic inflammation and thickening of the capillary basal membrane. Abnormalities
in early left ventricular diastolic filling are commonly seen in type II diabetes. Vascular
endothelial function is critical for maintaining structural and functional integrity of the
vessel walls as well as the vasomotor control. Nitric oxide (NO) mediates vasodilation,
and its decreased availability can cause endothelial dysfunction and trigger a cascade
of atherosclerosis. With these factors, there will be likely a chance to have stroke on
our patient.
According to the Diabetes UK, Diabetes can cause damage to your kidneys over a long
period of time making it harder to clear extra fluid and waste from your body. This is
caused by high blood sugar levels and high blood pressure. It is known as diabetic
nephropathy or kidney disease, suggesting kidney disease. Anemia is also one of the
commonest and prevalent blood-related disorder occurs in patients with diabetes. It
mostly occurs in DM patients who also have renal impairment. Evidence indicates
that the existence of anemia among T2DM is typically associated with the failure of
the kidney to produce appropriate erythropoietin. She shows signs of pallor, pale
palpebral conjunctiva and pale lips and mucosa. Some people with diabetes develop
an eye disease called diabetic retinopathy which can affect their eyesight. This is
present with our patient presenting with (-) ROR on left eye and blurring of vision.
There can also be gum disease caused by high blood sugar signifying dental caries.
Since diabetes can affect the blood circulation and can cause to have a build up of
fluid in the lower extremities called peripheral edema, showing the +2 bipedal edema
of the patient.
Differential Diagnosis:

Metabolic Syndrome
Rule in: The patient was diagnosed of having Diabetes mellitus having elevated blood
sugar and symptoms such as increased thirst and urination, weakness, and blurred
vision.
Rule out: The patient was not diagnosed of having hypertension and also there were
no signs of having a high cholesterol. The family history was also unremarkable.
Diagnostic tests needed to confirm:
Lipid Profile this can measure the amount of cholesterol and triglycerides in your blood
to ensure that there are no signs of having hypertension.

Diabetic Ketoacidosis
Rule in: The patient presented symptoms such as nausea, polyuria which is noted at
the ROS and was observed to be lethargic upon the admission.
Rule out: Along the symptoms noted, we have stated the pertinent negatives such as
presence of shortness of breath, abdominal pain and vomiting which are clearly not
observed with the patient. The patient was also not noted to be tachycardic and in
respiratory distress. Also, there were no signs of infection that may add to the
precipitating events like urinary tract infection and tissue ischemia.
Diagnostic tests needed to confirm:
Blood sugar level. If there isn't enough insulin in the body to allow sugar to enter cells,
the blood sugar level will rise.
Urinalysis. To check if there’s ongoing infection
Repeat laboratory tests are critical, including potassium, glucose, electrolytes, and, if
necessary, phosphorus.

Diabetes insipidus
Rule in: This disease is not connected to diabetes but it has the 2 most common
symptoms that were observed with our patient which are polydipsia and polyuria
Rule out: Since our patient was noted to have an elevated blood sugar, this is a strong
indication that we can rue this out since in Diabetes insipidus, the blood glucose levels
are normal, but the kidneys are the ones that cannot properly concentrate urine.
Diagnostic tests needed to confirm:
Genetic screening. If others in your family have had problems with excess urination,
your doctor may suggest genetic screening.
Magnetic resonance imaging (MRI). An MRI can look for abnormalities in or near the
pituitary gland.

Plans (Diet, Diagnostics, Drugs, Disposition):

Diagnostics:

• CT scan - uses multiple images to build up a more detailed 3-dimensional picture

of your brain to help your doctor identify any problem areas.

If a stroke is suspected, a CT scan is usually able to show whether you have had
an ischemic stroke or a hemorrhagic stroke.

• Complete Blood Count - should be requested due to presentations such as

pale conjunctiva and pale buccal mucosa which may be an indication of having
low hemoglobin. Also, to check if there is a reduction in platelets
(thrombocytopenia) and white blood cells (leukopenia).
• Serum ferritin - to assess the patient’s anemia due to blood loss.
• FBS and lipid profile test. Check for blood sugar level of the patient and the
current state of lipid of the patient for monitoring since he is diagnosed with
diabetes mellitus.
 • A1C test - measures your average blood sugar level over the past 2 or 3
months. An A1C below 5.7% is normal, between 5.7 and 6.4% indicates you
have prediabetes, and 6.5% or higher indicates you have diabetes.
• Urinalysis - Urinalysis is the most important noninvasive test in the initial
workup of acute kidney injury. Findings on urinalysis guide the differential
diagnosis and direct further workup
• Urine output - urine output can be used for diagnosis of acute kidney injury,
although patients who meet diagnostic criteria for both are at increased risk of
mortality from renal replacement therapy and hospitalization.
• Serum creatinine - It is important to compare the patient’s current serum
creatinine level with previous levels to determine the duration and acuity of the
disease. The definition of acute kidney injury indicates that a rise in creatinine
has occurred within 48 hours.
• Glucose urine test - measures the amount of sugar (glucose) in a urine
sample. The presence of glucose in the urine is called glycosuria or glucosuria.

Plans and Treatment:

Monitoring — Closely monitor the CBC of the patient especially his hemoglobin levels.
To monitor and assist cardiovascular, pulmonary, renal, and central nervous system
(CNS) function.

Intravenous access — for volume replacements, stabilize and monitor BP of the

patient.

Correct patient’s hyperglycemia – To stabilize and reduce symptoms of the patient

Medication:

Metformin (Fortamet, Glumetza, others) is generally the first medication prescribed

for type 2 diabetes. It works primarily by lowering glucose production in the liver and
improving your body's sensitivity to insulin so that your body uses insulin more
effectively. We start with 500 mg once daily with the evening meal and, if tolerated, add
a second 500 mg dose with breakfast. The dose can be increased slowly (one tablet
every one to two weeks) as tolerated to reach a total dose of 2000 mg per day.

Can be combined with Glipizide (Glucotrol) We initially start with 5 mg daily which will
be Taken once or twice (if >15 mg) daily.

To address the edema, The usual initial dose of Furosemide (Lasix) is 20 to 80 mg

given as a single dose. If needed, the same dose can be administered 6 to 8 hours later
or the dose may be increased. The dose may be raised by 20 or 40 mg and given not
sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has
been obtained.

Erythropoietin - Adults—Dose is based on body weight and must be determined. The

starting dose is 50 to 100 units per kilogram (kg) injected into a vein or under the skin
three times a week.
Disposition:

Patient should be admitted to the hospital for additional monitoring and evaluation.
Being admitted give immediate support if seizures occur. It may be best to reduce the
symptoms and reassess before discharge.

Upon discharge, patient is advised to;

Learn about carbohydrate counting and portion sizes. - Carbohydrates often have
the biggest impact on your blood sugar levels. For people taking mealtime insulin, it's
important to know the amount of carbohydrates in your food, so you get the proper
insulin dose.
Make every meal well balanced. As much as possible, plan for every meal to have a
good mix of starches, fruits and vegetables, proteins, and fats.
Avoid sugar-sweetened beverages. Sugar-sweetened beverages tend to be high in
calories and offer little nutrition. And because they cause blood sugar to rise quickly,
it's best to avoid these types of drinks.
Keep an exercise schedule. Talk to your doctor about the best time of day for you to
exercise so that your workout routine is coordinated with your meal and medication
schedules.
Check your blood sugar level - Check your blood sugar level before, during and after
exercise, especially if you take insulin or medications that lower blood sugar.
Exercise can lower your blood sugar levels even up to a day
Abstain alcohol – to this can aggravate diabetes complications, such as nerve
damage and eye disease. But if your diabetes is under control and your doctor
agrees, an occasional alcoholic drink is fine.
Blood sugar monitoring – Routinely checking your blood sugar can benefit you on
how you are doing with the medication and current lifestyle changes.

Name of Medical Student: ___Jose Mari S. Ignacio____

Year level 3
Date: __October 15, 2022__